Effective Date:  12/7/98

Policy Statement:

The minimum requirements for documents that comprise a client's case record are:

  • Child Care Application - Form 3455, Form 3455S*
  • Approval of Request for Child Care Payments - Form 3455A, 3455AS*
  • Denial of Request for Child Care Payments - Form 4179, 4179S*
  • Notice of Cancellation for Child Care Payments - Form 4178, 4178S*
  • Child Care Certificates - Form 3492, 3492A, or 3492B
  • Request for Additional Information - Form 4480, 4480S*
  • Request for a Child Care Provider Change - Form 3455G, 3455GS*
  • Request for Redetermination Information - Form 3455E, 3455ES*
  • Request for Reimbursement - Form 3455F
  • Two most recent and consecutive pay stubs or other income documentation
  • Responsibility and Service Plan (RSP) or other appropriate local office documentation

*Spanish version of the form.

The documents listed above are not required to be physically maintained in the same case record.

If copies of the Approval of Request for Child Care Payments, Denial of Request for Child Care Payments or Notice of Cancellation of Child Care Payments are not available, screen prints of the CCMS form generation request screen may also be placed in the file.  All CCMS generated forms may also be found stored electronically in the CCMS Documents tab.

CCR&R Directors and Site Administered Providers must establish adequate internal controls to ensure that files are maintained in a logical fashion and retrieval is possible without excessive delays.

If possible, documents comprising the file should be original, including original signatures, and be complete.

A case record may also contain other information in addition to the minimum requirements. Examples of other information are case notes, documentation of a phone conversation, and written correspondence.